Comparison of the Diagnostic Criteria for Autism Spectrum Disorder Across

DSM-5,1 DSM-IV-TR,2 and the Individuals with Disabilities Education Act (IDEA)3
Definition of Autism

Colleen M. Harker, M.S. & Wendy L. Stone, Ph.D.

University of Washington READi Lab (Research on Early Autism Detection and Intervention)
September 2014

Table 1: Comparison of DSM-5 and DSM-IV-TR Diagnostic Criteria

DSM-5 DSM-IV-TR
Diagnostic
Classification
Autism Spectrum Disorder (ASD) Pervasive Developmental Disorders Key Differences
Diagnostic None 1. Autistic Disorder Autism In DSM-5:
Subcategories 2. Asperger’s Disorder Spectrum There are no diagnostic
(However, it is specified that individuals with a well- Disorder(s) subcategories, reflecting
3. Pervasive Developmental Disorder,
established DSM-IV diagnosis of Autistic Disorder, research indicating a lack of
Asperger’s Disorder, or PDD-NOS should be given Not Otherwise Specified (PDD-NOS)
reliability across clinicians in
the diagnosis of ASD). 4. Rett’s Disorder assigning subcategories.
5. Childhood Disintegrative Disorder (CDD) ASD encompasses Autistic
Disorder, Asperger’s Disorder,
and PDD-NOS. Rett’s
Disorder and CDD are no
longer included in the ASD
diagnosis.
Requirement Must meet all 3 behavioral criteria in category A Must meet at least 6 behavioral criteria overall, with In DSM-5:
for Diagnosis and at least 2 in category B. (See below). at least two from category A.1, one from category It is now specified that
A.2, and one from A.3. (See below.) behavioral criteria can be met
on the basis of historical
report.
   

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 Social Communication & Social Interaction
(Category A)
Specific A. Persistent deficits in social communication
Behavioral and social interaction across multiple
Criteria: contexts, as manifested by all three of the
following, currently or by history:
SOCIAL
1. Deficits in social-emotional reciprocity,
ranging, for example, from abnormal social
approach and failure of normal back-and-
forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to
initiate or respond to social interactions.
2. Deficits in nonverbal communicative
behaviors used for social interaction, ranging,
for example, from poorly integrated verbal
and nonverbal communication; to
abnormalities in eye contact and body
language or deficits in understanding and
use of gestures; to a total lack of facial
expressions and nonverbal communication.
3. Deficits in developing, maintaining, and
understanding relationships, ranging, for
example, from difficulties adjusting behavior
to suit various social contexts; to difficulties in
sharing imaginative play or in making friends;
to absence of interest in peers.
N/A
Specific Symptoms in this area are now subsumed under
Behavioral Categories A (Social) and B (Restricted Activities)
Criteria:
LANGUAGE/
COMMUNICA-
TION
 
Social Interaction
(Category A.1)
A.1. Qualitative impairment in social interaction,
as manifested by at least two of the
following:
a. Marked impairments in the use of multiple
nonverbal behaviors such as eye-to-eye
gaze, facial expression, body posture, and
gestures to regulate social interaction.
b. Failure to develop peer relationships
appropriate to developmental level.
c. A lack of spontaneous seeking to share
enjoyment, interests, or achievements with
other people, (e.g., by a lack of showing,
bringing, or pointing out objects of interest to
other people).
d. Lack of social or emotional reciprocity (e.g.,
not actively participating in simple social
play or games, preferring solitary activities,
or involving others in activities only as tools
or "mechanical" aids).
Communication (Category A.2)
A.2. Qualitative impairments in communication
as manifested by at least one of the
following:
a. Delay in, or total lack of, the development of
spoken language (not accompanied by an
attempt to compensate through alternative
modes of communication such as gesture or
mime).
b. In individuals with adequate speech, marked
impairment in the ability to initiate or sustain
a conversation with others.
c. Stereotyped and repetitive use of language
or idiosyncratic language.
d. Lack of varied, spontaneous make-believe
play or social imitative play appropriate to
developmental level.
In DSM-5:
Social communication and
social interaction are
combined into one category, in
recognition that
communication is necessarily
social in nature, and based on
factor analytic studies.
It is specified that social
communication/ interaction
deficits must be manifested
across multiple contexts.
In DSM-5:
Language impairment (a) is
not included in the diagnostic
criteria, but is included as a
specifier (see ‘Specifiers’).
Impaired conversation (b) is
considered an aspect of
social-emotional reciprocity
(A.1).
Stereotyped language (c) is
considered an aspect of
restricted/repetitive behaviors
(B.1).
Social and imaginative play(d)
are incorporated into A.3.
2
 Restricted, repetitive behavior, interests, Restricted repetitive & stereotyped patterns
activities (Category B) of behavior (Category A.3)
Specific B. Restricted, repetitive patterns of behavior, A.3. Restricted repetitive and stereotyped In DSM-5:
Behavioral interests, or activities, as manifested by at patterns of behavior, interests and Sensory issues are now
Criteria: least two of the following, currently or by activities, as manifested by at least one of included as a behavioral
history. the following: symptom (B.4.).
RESTRICTED/
1. Stereotyped or repetitive motor movements, a. Encompassing preoccupation with one or
REPETITIVE
use of objects, or speech (e.g., simple motor more stereotyped and restricted patterns of
ACTIVITIES stereotypies, lining up toys or flipping objects, interest that is abnormal either in intensity or
echolalia, idiosyncratic phrases). focus.
2. Insistence on sameness, inflexible b. Apparently inflexible adherence to specific,
adherence to routines, or ritualized patterns nonfunctional routines or rituals.
or verbal nonverbal behavior (e.g., extreme c. Stereotyped and repetitive motor
distress at small changes, difficulties with mannerisms (e.g., hand or finger flapping or
transitions, rigid thinking patterns, greeting twisting, or complex whole-body
rituals, need to take same route or eat same movements).
food every day). d. Persistent preoccupation with parts of
3. Highly restricted, fixated interests that are objects.
abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual
objects, excessively circumscribed or
perseverative interest).
4. Hyper- or hyporeactivity to sensory input or
unusual interests in sensory aspects of the
environment (e.g., apparent indifference to
pain/temperature, adverse response to
specific sounds or textures, excessive
smelling or touching of objects, visual
fascination with lights or movement).
Age of Onset C. Symptoms must be present in the early B. Delays or abnormal functioning in at least one In DSM-5:
developmental period (but may not become of the 3 behavioral must be present prior to Symptoms do not have to be
fully manifest until social demands exceed age 3 years. apparent before age 3.
limited capacities, or may be masked by
learned strategies in later life).

 

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Level of D. Symptoms must cause clinically significant
Impairment impairment in social, occupational, or other
important areas of current functioning.
Rule-Outs E. These disturbances are not better explained
by intellectual disability (intellectual
developmental disorder) or global
developmental delay.
Comorbidities The following “Specifiers” should be indicated:
With or without accompanying intellectual
impairment.
With or without accompanying language
impairment.
Associated with a known medical or genetic
condition or environmental factor.
Associated with other neurodevelopmental,
mental, or behavioral disorder.
With catatonia.
 
Optional: Global Assessment of Functioning (0-100) In DSM-5:
may be used. Functional impairment must be
present for a diagnosis.
Severity levels for behavioral
criteria A and B must be
specified:
Level 3: Requiring very
substantial support
Level 2: Requiring substantial
support
Level 1: Requiring support
C. The disturbance is not better accounted for In DSM-5:
by another Pervasive Developmental Social (Pragmatic)
Disorder. Communication Disorder
(SCD) is presented as an
alternative (new) diagnosis for
individuals who have marked
deficits in social
communication, but whose
symptoms do not otherwise
meet criteria for ASD.
ADHD and Stereotyped Movement Disorder cannot In DSM-5:
be diagnosed along with Autistic Disorder. Comorbidities with other
conditions are recognized;
Specifiers are used to further
describe the symptomatology.
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 Summary of Research Findings Comparing DSM-5 and DSM-IV-TR Criteria for Autism

Several studies have compared the DSM-5 criteria to the DSM-IV-TR criteria in clinical samples. The majority have used retrospective methods (e.g., record
4-9
review) to apply DSM-5 criteria to individuals with an established DSM-IV-TR diagnosis. Interpretation of these findings is challenging, because the initial
diagnoses were based on the DSM-IV-TR criteria, which did not include some behavioral criteria specified in DSM-5. Four studies compared the use of DSM-IV-
10-13 14
TR and DSM-5 diagnostic criteria on the same contemporaneous sample, and one conducted a meta-analysis of studies that used both contemporaneous
9, 11,13 7 4-
and retrospective approaches. Only three studies used the current published DSM-5 criteria; the others used draft versions from either 2010 or 2011.
6,8,10,12 14
, The meta-analysis reported similar findings for studies applying the 2010 and 2011 DSM-5 draft criteria.
5-7,10,12,13
Most studies report that DSM-5 criteria, compared to DSM-IV-TR criteria, result in fewer individuals diagnosed with ASD. The reduction rate across these
8
studies ranged from 25%-68%, though one study found only a 9% reduction, or sensitivity of .91. One study reported that higher-functioning individuals in the
10
PDD-NOS subgroup were less likely to receive a DSM-5 diagnosis of ASD than were individuals in the other DSM-IV-TR subgroups. While some studies
reported that females, young children, and/or non-cognitively impaired individuals with a DSM-IV-TR diagnosis were disproportionately under-identified using
4-6 8,13
DSM-5 criteria, others reported similar identification rates for these subgroups. One study found that a failure to satisfy all three criteria in the social-
13
communication domain of DSM-5 was the most common reason (39%) that individuals with a DSM-IV-TR diagnosis did not receive a DSM-5 diagnosis of ASD.
Findings are mixed regarding the extent to which the new DSM-5 diagnosis of Social Communication Disorder (SCD) is successful in capturing individuals with a
11,12
DSM-IV-TR diagnosis who do not meet DSM-5 diagnostic criteria for ASD.

Table  2:  Comparison  of  IDEA  Definition  of  Autism  and  DSM-­‐5  Diagnostic  Criteria  

IDEA Definition Similarities with DSM-5 Differences from DSM-5

“Autism means a developmental disability Both definitions include IDEA uses the classification of ‘autism,’ while DSM-5 uses the classification of
significantly affecting verbal and nonverbal symptoms in the areas of ‘autism spectrum disorder (ASD).’
communication and social interaction, social interactions, DSM-5 presents more detailed behavioral descriptions for each symptom.
generally evident before age three, that nonverbal communication, DSM-5 provides an algorithm for how many symptoms in each behavioral
adversely affects a child’s educational repetitive activities, domain are required for a diagnosis.
performance. Other characteristics often stereotyped movements, IDEA provides more detailed description for stereotyped activities than for
associated with autism are engagement in resistance to change, and social impairments, suggesting an emphasis on the former.
repetitive activities and stereotyped unusual sensory responses. IDEA specifies that the symptoms must adversely affect the child’s educational
movements, resistance to environmental Both definitions indicate that performance, while DSM-5 requires impairment in social, occupational, or other
change or change in daily routines, and symptoms need not be important areas of functioning.
unusual responses to sensory experiences. apparent before age 3. DSM-5 requires the specification of severity levels for the two behavioral
A child who manifests the characteristics of domains.
autism after age three could be identified as DSM-5 uses “specifiers” to describe co-morbidities, such as language and
having autism if the aforementioned criteria intellectual impairment.
are satisfied. Autism does not apply if a
child’s educational performance is adversely
affected primarily because the child has an
emotional disturbance, as defined in
paragraph (c)(4) of IDEA.”

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The contents of this document were developed under a grant from the U.S. Department of Education, H325E120002. However, those contents do not necessarily
represent the policy of the U.S. Department of Education, and you should not assume endorsement by the Federal Government. Project Officers, Sarah Allen and
Tracie Dickson.
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